1. An Inter-Professional Collaboration between a Family Medicine Center and a School of Nursing Maritza De La Rosa, MD New Jersey Family Practice Center Rutgers, New Jersey Medical School Shelby Pitts, MSN, RN,WHNP-BC Rutgers University School of Nursing

2. Disclosures The presenter(s) has no relevant financial interest or other relationship with the commercial supporter(s) of this educational activity or with the manufacturer(s) of any commercial product(s) and/or providers of commercial services discussed in this educational activity.

3. Overview Case managers are critically important in today’s Patient Center Medical Home for the best practices of management of complex patients with diabetes. The aim of this clinical experience is to provide diabetes care coordination using an interdisciplinary model of care with senior level nursing students.

4. Project Goals Develop and implement a collaboration model between the New Jersey Family Practice Center and senior nursing students Provide interdisciplinary approach for better coordination of care in an effort to improve patient outcomes Nursing students will broaden their scope of practice and learn skills needed to treat patients with chronic problems and limited resources in an outpatient setting Establish timeline to adequately measure overall improvement of patient follow up/ adherence post implementation.

5. Presentation Objectives Recognize the need for care coordination as an essential aspect for patient’s health improvement Describe barriers to health care and explore possible interventions available or to be developed to overcome these barriers Develop an understanding of possible creative resources available to assist providers managing their patients with chronic illnesses

6. New Jersey Family Practice Center (NJFPC) Provides primary care services to residents in Newark, NJ Staff: 2 Part-time physicians - (FTE 0.9) and 2 Medical Assistants 3,431Visits per year High-risk, complex care, urban minority population Two third of patients - HMO/Medicaid One-third of patients - Medicare and Self-pay Teaching clinical site for 3 rd year medical students

7. Senior Nursing Students: Role as Care Coordinators Each student was assigned a case load 8- 10 patients with Diabetes Patients assigned by providers based on poor health outcome Same patients followed for 3 semesters by each group of students

8. Senior Nursing Students: Role as Care Coordinators Students had weekly interdisciplinary rounds-individual patient plan of care Chart review for each patient – recommendations up to date and follow up Patients were contacted via telephone for follow up using “script tool”

9. Senior Nursing Students: Role as Care Coordinators Called patients for follow up appointments, referrals, and/or reminders Medication compliance/ medication refills Patients due for blood work up Navigation of healthcare system

10. Senior Nursing Students: Role as Care Coordinators Students assisted with access to care barriers: –Transportation –Appointments with specialists –Obtaining consults reports –Medications

11. Senior Nursing Students: Role as Care Coordinators Students provided individualized teaching sessions specific to diabetes education –Medication administration –Nutrition –Exercise –Smoking cessation

12. Group Teaching Activities Required project at the end of rotation Prepare and conduct group teaching activity available and offered to all patients at the Center

13. Senior Nursing Students: Group Teaching Activities

17. Results

20. Post Collaboration BP Management N=55 100% patients 11 20% BP Uncontrolled 10 91% medication or lifestyle modification 1 9% no changes (missed opportunity) 44 80% BP Controlled

21. Urine Micro albumin

22. Post Collaboration Microalbuminuria Treatment N=55 2449 1930 22 5 3 7% Not measured 73% ACE/ARB Treatment 17% Side effect 10% Missed 4% ESRD 89% Measured 61% Elevated 39% Normal

23. Results

24. Results Summary HgA1c levels- 58.2% of all patients showed improvement Blood pressure- BP control increase from 55% to 80% Patients with diabetes who had urine micro albumin measured increased from 53% to 89% 90% of patients with elevated urine micro albumin treated Improvement is needed in treating patients with diabetes and LDL>70<100 to reduce their LDL levels by 30-50%

25. Patient Satisfaction 65% patients feel reminders calls from students were helpful 100% of patients who attended educational sessions believe it helped them to achieve better control of their diabetes 85% of patients are interested in having more educational sessions

26. Student Satisfaction 82% of students were satisfied with Family Medicine experience. 72% are likely to recommend clinical experience to other students. 100% students replied increase in knowledge on diabetes case management, critical thinking skills and patient teaching skills.

27. Limitations Continuity of care based on student academic calendar Medical provider left practice Patient compliance with medical follow up

28. Conclusions Innovative approach to improve care coordination and overall health outcomes among diabetes population Interdisciplinary education model with Family Medicine partnering with the School of Nursing Improve quality of care and patient’s overall health Nursing educational experience as independent care provider in outpatient setting

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